Addictive Behaviors 37 (2012) 367–372

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Addictive Behaviors

Early onset of drug and polysubstance use as predictors of injection drug use among
adult drug users
Rebecca C. Trenz ⁎, Michael Scherer, Paul Harrell, Julia Zur, Ashish Sinha, William Latimer
Johns Hopkins University Bloomberg School of Public Health, United States

a r t i c l e i n f o a b s t r a c t

Keywords: Early onset of alcohol, marijuana, and cigarette use is an indicator of later substance use problems in adult-
Early onset hood such as alcohol or other drug dependence. This paper seeks to address the association between early
Polysubstance use onset alcohol, marijuana, cigarette, and polysubstance use with injection drug use among recent illicit drug
Injection drug use
users. The current study used baseline data from the Baltimore site of the NEURO-HIV Epidemiologic
Non-injection drug use
Study, an investigation of neuropsychological and social–behavioral risk factors of HIV, hepatitis A, hepatitis
Heroin
B, and Hepatitis C among both injection and non-injection drug users in Baltimore, Maryland. The present
study used a subset (N = 651) of the larger parent study that identified as White or Black, and reported
any drug use in the past 6 months. In the full sample slightly more than half (52.5%) of study participants
were IDUs. IDUs differed from non-IDUs on age of initiation for cigarettes, marijuana, and alcohol, with
IDUs initiating the use of all three substances significantly earlier than non-IDUs. IDUs also had significantly
greater proportions of early onset of alcohol (χ 2 = 19.71, p b .01), cigarette (χ 2 = 11.05, p b .01), marijuana
(χ2 = 10.83, p b .01), and polysubstance use (χ2 = 23.48, p b .01) than non-IDUs. After adjusting for age,
gender, and race/ethnicity, only participants identified as early onset alcohol users (AOR = 1.47, 95% CI:
1.00–2.18) and early onset polysubstance users (AOR = 1.62, 95% CI: 1.10–2.38) were more likely to have
IDU status than those who reported initiating substance use later. IDU status was then stratified by race/
ethnicity. After controlling for age and gender, only early polysubstance use was a significant predictor of
IDU status for Whites (AOR = 2.06, 95% CI: 1.07–3.93). Consistent with literature on early substance initia-
tion and later illicit substance use, early onset of alcohol and polysubstance use is an important risk factor
for IDU in adulthood.
© 2011 Elsevier Ltd. All rights reserved.

1. Introduction
Extant literature has investigated the epidemiologic trends and
risk factors associated with adolescent exposure to alcohol, cigarettes,
and marijuana and the subsequent use of these substances beyond
experimentation (For a review, see Latimer & Zur, 2010). In addition,
a substantial body of research has provided evidence that early onset
drug use has been associated with drug use problems in adulthood
(Anthony & Petronis, 1995; Chen, Sorr, & Anthony, 2009; Kandel,
Yamaguchi, & Chen, 1992); specifically, early onset of alcohol, mari-
juana, and cigarette use are indicators of potential later adulthood
problems such as alcohol abuse and dependence or other drug depen-
dence (Dawson, Goldstein, Chou, Ruan, & Grant, 2008; Grant, 1998;
Grant & Dawson, 1997; Grant, Stinson, & Harford, 2001; King &
Chassin, 2007). It stands to reason that this same line of research
⁎ Corresponding author at: Mercy College, School of Social and Behavioral Sciences,
Mahoney Hall, 555 Broadway, Dobbs Ferry, NY 10522, United States. Tel.: 914 674 2327;
fax: 914 674 7413.
E-mail address: rtrenz@mercy.edu (R.C. Trenz).
can be applied specifically to injection drug use (IDU), but remains
a developmental trajectory that is infrequently addressed. This may
be partially due to the fact that early onset substance use and later
injection drug use are challenging to study in national data sets be-
cause illicit drug use in these large samples is often small (Hedden
et al., 2010). In addition, many urban areas such as Baltimore have
high rates of reported past year illicit drug dependence or abuse
(SAMSHA, 2008) thereby increasing exposure to substance using
environments.
The current paper seeks to address the association between early
onset drug use and early onset polysubstance use with injection
drug use, in particular, substance use at or before age 15 among a
population of recent illicit drug users. Indicators of early substance
use among this population may give practitioners insight into initial
exposure to drug using environments that may extend to the use of
injection drugs in adulthood. An investigation into this developmen-
tal trajectory of substance use has important public health concerns
given the link between IDU and the associated risk of HIV and
hepatitis C infection.
Nationally, the Substance Abuse and Mental Health Services
Administration (SAMSHA, 2009) has reported an annual average

0306-4603/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.addbeh.2011.11.011
368 R.C. Trenz et al. / Addictive Behaviors 37 (2012) 367–372
rate of 425,000 IDUs over the age of 12 and a peak in IDU in young
adults between the ages of 18 to 25. In addition, NIDA (2010) notes
that IDUs are the highest risk group for HCV and HIV infection. On a
local level, injection drug use continues to be a public health
concern in low-income, inner-city neighborhoods such as Baltimore,
Maryland, particularly with regard to HIV risk (Mitchell & Latimer,
2009) and infection (Fuller et al., 2005; Sherman et al., 2005).
Research focusing on IDU in Baltimore has identified many factors
contributing to IDU in this urban setting, including dropping out of
high school, homelessness, physical violence (Fuller et al., 2002),
and childhood sexual abuse (Ompad et al., 2005). Further, environ-
mental factors such as low education levels, racial segregation and
poverty (Fuller et al., 2005), co-occurring disorders of dependence
(Arria, Fuller, Strathdee, Latkin, & Vlahov, 2002), race, sexual practices,
smoking crack and marijuana (Fuller et al., 2001), and being younger
at age of first alcohol, marijuana, and inhalant drug use contribute to
the initiation of IDU (Sherman et al., 2005). Although these studies
provide a framework for correlates of IDU and factors that contribute
to the transition to IDU, to our knowledge, no studies to date have
investigated the early onset of alcohol, cigarette, marijuana and poly-
substance use prior to age 15 as a predictor of IDU in adulthood.
This appears to be a critical omission in the literature when we
consider that alcohol is currently the most commonly used substance
among adolescents in the United States followed by cigarettes and
marijuana (Johnston, O'Malley, Bachman, & Schulenberg, 2009). Pre-
vious studies investigating the developmental trajectory of substance
use behaviors have established that the early onset of alcohol for
males and tobacco for females precedes marijuana use and, subse-
quently, the use of more deleterious substances such as crack cocaine
or injection of heroin (Golub & Johnson, 2001; Kandel & Yamaguchi,
1993; Yamaguchi & Kandel, 1984). In addition, early drug use has
been associated with increased odds of cannabis, stimulant, cocaine,
opioid, and hallucinogen dependence among individuals who reported
treatment for alcoholism (Sintov, Kendler, Walsh, Patterson, & Prescott,
2009). The relationship between early drug use and later drug problems
may be particularly viable in cases where adolescents engage in poly-
substance use (Weinberg, Rahdert, Colliver, & Glantz, 1998) and is an
area of research that needs additional consideration with regard to
early onset substance use and specific drug use outcomes in adulthood,
such as IDU.
In the substance abuse literature, early onset has been defined and
categorized in various ways. Often, the course of substance use is
thought to adhere to a developmental trajectory that begins with
experimentation in adolescence and evolves into abuse or depen-
dence in adulthood (Chassin, Hussong, & Beltran, 2009; Masten,
Faden, Zucker, & Spear, 2008). Research in this domain has highlight-
ed the importance of investigating the onset of substance use in early
adolescence as indicator of risk for more illicit substance use later in
life. For example, in a study of the progression of drug use among
young adults in New York state, Yu and Williford (1992), found
that the onset of substance use during the critical developmental
period between the ages of 13 and 16, particularly alcohol, had a
stronger impact on the current use of alcohol and other drugs than
the initiation of substances during any other age period. In addition,
adolescents who begin alcohol use before age 14 are more likely to
develop alcohol dependence in adulthood than those that begin
drinking after 21 years of age (Grant & Dawson, 1997). Furthermore,
in an analysis of the Youth Risk Behavior Survey, Lee and Abdel-
Ghany (2004) found that the most prevalent age for the onset of
drinking alcohol and smoking cigarettes or marijuana is between 13
and 14 years old. Lastly, DeWit, Adlaf, Offord, and Ogborne (2000)
found that adolescents who began to drink before age 15 had a 2 to
3 times greater risk of developing alcohol dependence compared
to youth who started drinking at age 19 or later. As such, exploring
the early onset of substance use at or prior to 15 years of age seems
particularly pertinent.
Early onset of substance use is of particular concern during adoles-
cence as research has begun to emerge which shows exposure to
alcohol and/or marijuana has detrimental neurotoxic effects on
brain chemistry and may interfere with neurodevelopment. This
may result in difficulties with higher executive functions such as
problem-solving, planning, decision-making, judgment, and selective
attention, as well as the development of reward systems and self-
control (Brown et al., 2008; Chassin et al., 2009; Lezak, 1995). Further,
the early onset of substances may have continuing detriments to
executive functioning such as self-regulation which is crucial in
later adolescence – particularly for those who have drug-using
peers – when they may be more likely to be confronted with having
to make decisions in risky situations such as driving while intoxicated,
having unsafe sex, or escalating drug use (Brown et al., 2008). Though
much literature has been devoted to exploring and understanding
the many consequences associated with early initiation of substances
and the resulting impact later in life, research has yet to address
the consequences of early onset of alcohol, cigarette, marijuana, both
individually or in conjunction with one another, as they specifically
relate to IDU in adulthood.
As previous work has explored the correlates of early initiation
into IDU and the transition among substance users to IDU, to our
knowledge, no studies have specifically addressed early onset sub-
stance use and polysubstance use as a predictor of IDU among adult
substance users. To date the majority of research investigating early
onset substance and subsequent illicit drug use has neglected to spec-
ify IDU as an outcome. Generally, when discussing outcomes of early
onset of substance use, studies in this area have grouped all other
substances together as “other illicit drugs.” In doing so, previous
research neglects differences between route of administration of illic-
it drugs and overlooks subtle yet potentially vital nuances of early
substance use, singularly and in combination, as predictors of both in-
jection and non-injection drug use. The current study seeks to explore
early onset alcohol, cigarette, marijuana, and polysubstance use at or
before age 15 and its association with injection drug use, specifically,
in adulthood in an effort to begin to address this gap.
2. Methods
2.1. Design and sample
Data for this study were obtained from the Baltimore site of the
NEURO-HIV Epidemiologic Study and has been described in detail in
other publications (Mitchell & Latimer, 2009; Severtson, Mitchell,
Manch, & Latimer, 2009). This study was designed to examine neuro-
psychological and social–behavioral risk factors of HIV, hepatitis A,
hepatitis B, and hepatitis C among both injection and non-injection
drug users in Baltimore, Maryland. This study was approved by the
Institutional Review Board at the Johns Hopkins Bloomberg School
of Public Health in 2001 and has received annual renewals. The
design of this study is cross-sectional. Participants completed the
HIV-Risk Behavior Inventory, a detailed behavioral assessment of
drug use and sexual practices. Inclusion criteria in the parent study,
required participants to be between the ages of 15 and 50 years
old and had to report use of non-injection and/or injection drugs in
the past 6 months. Recruitment strategies for participation included
advertisements in local papers, street outreach, and referrals from
local service agencies. Participants provided written informed con-
sent and completed a face-to-face HIV-Risk Behavior Interview. In
addition, participants completed a battery of neuropsychological
tests that measured executive functioning and estimated general
intelligence. Blood and urine samples were obtained to test for the
presence of drugs and STDs. Participants were remunerated $45 for
the baseline assessment.
The present study used a subset (N = 651) of the parent study
that included participants who self-identified as White or Black.
 R.C. Trenz et al. / Addictive Behaviors 37 (2012) 367–372 369

Participants who self-identified as “other,” were not included in the
current analyses due to their small number (n = 23). Overall, partici-
pants in the current study had a mean age of 32.34 (SD = 8.21) and
were primarily Black (53.1%) and male (56.1%). The majority of par-
ticipants identified themselves as single (70.0%) and having achieved
a general education diploma (GED) or greater (55.0%). Forty-three
percent of the participants reported receiving money from regular
employment and 42.0% reported receiving money from public assis-
tance, while 18.0% reported homelessness in the 6 months prior to
the study. Sample characteristics are also described in Table 2 by
IDU status.
2.2. Measures
2.2.1. Demographic variables
The demographic items included in the analyses were age, sex,
and race/ethnicity. The two categories of race/ethnicity were White
and Black. Age was used as a continuous variable.
2.2.2. Drug use variables
Participants were asked to report the first time they recalled using
each drug outlined in the HIV-Risk Behavior Inventory. Participants
also self-reported past 6 month use of these substances. A summary
of the prevalence of recent substance use of the sample can be
found in Table 1.
2.3. Data analysis
The study data were summarized descriptively with frequency
distributions, means, and standard deviations. Chi-squares and
t-tests were used to identify significant differences between injection
and non-injection drug users on demographic variables and sub-
stance use at or before age 15. Univariate correlates that achieved
significance of less than .01 were retained for inclusion in the multi-
variable logistic analyses. Although there were no significant differ-
ences of age between groups on IDU status, this variable was
retained in the logistic analyses as a control mechanism for duration
of substance use. The binary indicator for injection drug use status
(i.e. IDU versus non-IDU status) was the dependent variable in the
logistic regression models. Predictors included alcohol, cigarette,
marijuana, and polysubstance use prior to age 15, in addition to
demographic variables. Separate binary logistic regression analyses
were used to assess the influence of substance use at or before age
15 on injection drug use status while controlling for age, sex, and
race. Groups were then stratified by race and binary logistic analyses
were run for each predictor variable while controlling for age and
gender. All data analysis was performed using PASW Statistics 18
(SPSS, 2009).
3. Results
3.1. Prevalence of recent drug use

2.2.3. Early onset substance use
Age of initiation of cigarette, marijuana, and alcohol use was
assessed with items: “How old were you when you first used ciga-
rettes?,” “How old were you when you first used marijuana?,” and
“How old were you when you first used alcohol?” Participants
responded to these questions with age in years. These continuous
age variables were transformed into dichotomous variables where
early onset substance use was categorized as ≤15 (coded as 1) and
>15 (coded as 0) for the descriptive and logistic regression analyses.
In the full sample slightly more than half (52.5%) of study partici-
pants reported IDU in some form in the past 6 months. A summary of
past 6 month drug use can be found in Table 1. The majority of the
participants drank alcohol (71.1%), smoked cigarettes (89.2%), and/
or smoked marijuana (52.4%) in the past 6 months. The prevalence
of IDU took several forms including injecting speedball (30.9%),
heroin (49%), and cocaine (31.4%). The prevalence of non-injection
drug use in the past 6 months included snorting speedball (9.8%),
heroin (43.0%), cocaine (20.6%), and smoking crack (46.0%).

3.2. Demographic characteristics stratified by injection drug use status

2.2.4. Early onset polysubstance use
Polysubstance use was defined as the use of any two or all three
substances (alcohol, cigarettes, marijuana) at or before age 15. Use
of any two or more substances was coded as a 1 and less than the
use of any two substances was coded as 0 in the logistic regression
analyses.
2.2.5. Injection drug use
Current IDU status was determined with the question: “Have
you injected any drugs in the past 6 months?” Participants who
responded yes to this question were coded with a 1 and those who
responded no were coded as a 0 in the logistic regression analyses.
Frequency distributions for each of the demographic and study
variables were determined for the entire sample of recent substance
users and were stratified by IDU status (Table 2). Of IDUs, 62% were
male and 38% were female. Of non-IDUs there was a fairly even split
by gender where 49.5% were male and 50.5% were female. The IDU
group was primarily White (67.8%) while the majority of the non-
Table 2
Demographic and drug use variables for injection and non-injection drug users
(N = 651).
Injectors Non-injectors

n = 342 n = 309 t/χ2 p

Table 1 Demographic variables M/N SD/% M/N SD/%
Summary of past 6 month drug use among the study sample Age 32.70 8.63 32.01 7.81 1.06 .289
(N = 651). Sex: male 212 32.6 153 23.5 9.75 .002
Female 130 20 156 24.0
Drug type and method of use %
Ethnicity: White 232 35.6 73 11.2 125.66 b.001
Drank alcohol 71.1 Black 110 16.9 236 36.3
Smoked cigarettes 89.2 Age of initiation
Smoked marijuana 52.4 Alcohol 13.38 3.18 14.56 3.73 3.56 b.001
Injected speedball 30.9 Cigarettes 13.71 4.14 15.01 4.31 3.71 b.001
Snorted speedball 9.8 Marijuana 13.94 3.07 15.01 3.13 4.71 b.001
Injected heroin 49.0 Substance use ≤ 15
Snorted heroin 43.0 Alcohol 253 40.2 175 27.8 19.71 b.001
Injected cocaine 31.4 Cigarettes 244 40.9 167 28.0 11.05 b.001
Snorted cocaine 20.6 Marijuana 244 39.3 181 29.1 10.83 b.001
Smoked crack 46.0 Polysubstance use 257 39.7 176 27.2 23.48 b.001

Note. Less than 2% missing data. Note. Less than 2% missing data.
370 R.C. Trenz et al. / Addictive Behaviors 37 (2012) 367–372

IDU group was primarily Black (76.3%). The mean age did not differ Table 4
significantly between IDU (M = 32.70, SD = 8.63) and non-IDU Summary of adjusted odds ratios for logistic regression analyses using early onset
substance use as a predictor of injection drug use stratified by race.
(M = 32.01, SD = 7.81) groups. IDUs differed from non-IDUs on age
of initiation for cigarettes (t = 3.71, p b .001), marijuana (t = 4.71, White Black
p b .001), and alcohol (t = 3.56, p b .001), with IDUs initiating the AOR 95% CI AOR 95% CI
use of all three substances significantly earlier than non-IDUs. IDUs
Predictors
also had significantly greater proportions of early onset of alcohol Cigarette use ≤ 15
(χ 2 = 19.71, p b .001), cigarette (χ 2 = 11.05, p b .001), marijuana No 1.00 1.00
(χ 2 = 10.83, p b .001), and polysubstances (χ 2 = 23.48, p b .001) than Yes 1.59 .82–3.07 1.22 .74–2.00
non-IDUs. Marijuana use ≤ 15
No 1.00 1.00
Yes 1.89 .97–3.66 1.12 .69–1.82
Alcohol use ≤ 15
3.3. Predictors of injection drug use
No 1.00 1.00
Yes 1.59 .78–3.22 1.43 .89–2.30
The unadjusted and adjusted logistic models stratified by IDU Polysubstance use ≤ 15
status can be found in Table 3. After adjusting for age, sex, and race/ No 1.00 1.00
ethnicity, early onset of alcohol (AOR = 1.47, 95% CI: 1.00–2.18) and Yes 2.06⁎ 1.07–3.93 1.43 .89–2.29
early onset polysubstance users (AOR = 1.62, 95% CI: 1.10–2.38) Note. AOR are adjusted for age and sex.
were more likely to have IDU status than those who reported initiat- ⁎ p b .05.

ing substance use later. Table 4 shows the adjusted odds ratios
for early substance use as a predictor of IDU status stratified by
of IDU among adult substance users and substantially contributes to
race/ethnicity. After controlling for age and sex, only early polysub-
this growing body of research.
stance use was a significant predictor of IDU status for Whites
After stratifying by race/ethnicity, early onset polysubstance use
(AOR = 2.06, 95% CI: 1.07–3.93).
was a risk factor of IDU among Whites, but not Blacks in this sample.
The lack of significance at the p b .05 for early polysubstance use onset
4. Discussion and IDU may be a function of differential patterns in substance initia-
tion between race/ethnicity. In fact, White, Jarrett, Valencia, Loeber,
The purpose of this study was to examine the relationship be- and Wei (2007) suggest different sequences of substance initiation
tween early onset of alcohol, cigarette, marijuana, and polysubstance between White and Black adolescent males. Specifically, Whites
use and injection drug use status among a sample of recent substance may be more likely to follow a typical initiation sequence of alcohol
users. Both early onset of alcohol use and polysubstance use were or tobacco to marijuana and then harder drugs (i.e. cocaine, crack,
risk factors for IDU, though polysubstance use was found to have a heroin). In contrast, a typical initiation sequence for Blacks may be
greater odds ratio of predicting IDU. The early onset of alcohol use alcohol, tobacco, marijuana, and then harder drugs. The null findings
is consistent with research that suggests alcohol may promote in- for Blacks in the stratified analysis may be a function of limited power
volvement in other illicit substance use such as IDU (Corsi, Winch, given the small cell size of Black IDUs, as per differences in develop-
Kwiatkowski, & Booth, 2007; Fergusson, Boden, & Horwood, 2008). mental sequences of substance initiation. As a result of these potential
Exploring polysubstance use in adolescence is a growing, yet still developmental differences in early onset of alcohol and polysub-
underdeveloped trend in substance use as it is an important risk fac- stance use should not be dismissed as a risk factor for this group,
tor for IDU in adulthood. In an early longitudinal study of adolescents, instead, further research is warranted to determine the impact on
Newcomb and Bentler (1988) investigated the effects of early early onset of alcohol and polysubstance use among Black popula-
substance use on seven problem domains in early adulthood. These tions in which larger sample sizes are available for sufficient power.
researchers found that polysubstance use in adolescence was predic- The significant finding of early onset polysubstance use and subse-
tive of increased problems with drugs in young adulthood, albeit not quent risk of IDU in adulthood should not overshadow the risk asso-
specifically IDU. To our knowledge, the present study is the first to ciated with early onset of other drug use, such as marijuana. For
identify early onset substance use (identified separately) and poly- example, Grant et al. (2010) found that among male twins, early
substance use (identified in combination) as a significant predictor onset users (use prior to age 18) of marijuana were 1.3 to 2.5 times
more likely to have tried other illegal drugs and were 1.0 to 1.2
times more likely to have illegal drug abuse/dependence than later
Table 3 users of marijuana. Similarly in another twin study, Lynskey, Vink,
Summary of unadjusted and adjusted odds ratios for logistic regression analyses using and Boomsma (2006) found that individuals who used marijuana
early onset substance use as a predictor of injection drug use.
prior to age 17 were 2.1 to 5.2 times more likely to have used other
OR 95% CI AOR 95% CI illicit drugs, have alcohol dependence, and drug abuse/dependence
Predictors than their co-twin. In addition, adolescents in a drug prevention pro-
Cigarette use ≤ 15 gram that reported earlier initiation of marijuana were more likely to
No 1.00 1.00 report other illicit drug use than those who reported later marijuana
Yes 1.84⁎⁎ 1.29–2.61 1.34 .90–1.99 initiation (Ellickson, D'Amico, Collins, & Klein, 2005). Moreover,
Marijuana use ≤ 15
No 1.00 1.00
Agrawal et al. (2006) found that among female twin pairs, other illicit
Yes 1.80⁎⁎ 1.28–2.53 1.34 .90–2.00 drug use was associated with the use of alcohol before 14 and the use
Alcohol use ≤ 15 of marijuana before 16, but not with early use of nicotine. Although
No 1.00 1.00 the present study did not demonstrate significance for early onset
Yes 2.19⁎⁎ 1.55–3.08 1.47⁎ 1.00–2.18
cigarette and marijuana use as a predictor of IDU, our study specifical-
Polysubstance use ≤ 15
No 1.00 1.00 ly indicates IDU as a substance use outcome and in this respect adds
Yes 2.31⁎⁎ 1.65–3.22 1.62⁎⁎ 1.10–2.38 to literature on early onset substance use and IDU in adulthood.
Note. AOR are adjusted for age, sex, and ethnicity.
One alternative explanation for harder drug use later in life is that
⁎ p b .05. the earlier exposure to alcohol, cigarettes, and marijuana equates to
⁎⁎ p b .01. a longer duration of risk (Degenhardt et al., 2009) and exposure to a
 R.C. Trenz et al. / Addictive Behaviors 37 (2012) 367–372
range of family and individual factors (Fergusson et al., 2008). Early
access and exposure to drugs may eliminate obstacles in acceptance
of and access to harder drug use (Lynskey et al., 2003). Yu and
Williford (1992) identified between 13 and 16 years of age as a criti-
cal period for substance exposure, as this developmental time frame
is filled with social and cognitive changes as well as peer influences.
These researchers theorized that alcohol use beginning within this
developmental time frame has a large impact on future drug use
behavior. In addition, Sobeck, Abbey, et al. (2000) explained that in-
creased exposure to substance use allows for modeling and reinforce-
ment to occur. The combination of reduced barriers and increased
exposure, observational learning, and relationships with peers is
one of the most common explanations for escalations in substance
use among young adults.
Several studies focusing on substance use and neurocognitive
functioning in adolescence, have documented a variety of executive
functioning deficits among adolescent substance users. For example,
adolescent marijuana users showed greater effort to achieve inhibi-
tion on an inhibition task than non-marijuana users (Tapert et al.,
2007) and non-dependent substance using adolescents without a
family history of substance use performed better on attention and
language tasks than substance dependent adolescents (Tapert &
Brown, 2000). In addition, prolonged alcohol and other drug use
among adolescents resulted in poorer performance on executive
functioning tasks that measured attention, memory, and visuospatial
functioning (Brown, Tapert, Granholm, & Delis, 2000; Tapert &
Brown, 1999; Tapert, Granholm, Leedy, & Brown, 2002). Poorer
performance on executive functioning tasks among adolescent
substance users suggest a reduced ability to control behavior and
attend to environmental stimuli which may put individuals at greater
risk for substance use later in life.
While the findings presented here provide valuable contributions
to the literature, there are limitations in the cross-sectional design
that reduce the ability to make causal inferences and to generalize
to other populations. These findings may be specific to heavy illicit
drug users in an urban setting and are not generalizable to larger,
non-illicit drug using populations or to former illicit drug users who
have periods of abstinence. Further, in retrospective studies, there
is great reliance on the self-report of drug use history. Specifically,
participants may have over or under-reported their age of first use
and recent drug use. However, given these limitations, self-reports
of drug use history provide detailed information over longer periods
of time compared to blood tests and urine analysis and, as such,
were appropriately used in this study. In a review of self-report of
injection drug users, Darke (1998) concludes that using self-report
is a reliable and valid method of describing drug use.
Despite these limitations, this study adds to prior literature
(Guttmannova et al., 2011; Zamboanga, Ham, Van Tyne, & Pole,
2011) suggesting that delaying drug use in adolescence may be pro-
tective against substance use in adulthood. However, further research
is needed to rule out other potential explanations, such as genetics.
Another strength of this study is that early onset drug use is often
studied using adolescent participation in large scale, cross-sectional,
national surveys such as Monitoring the Future (MTF; Johnston
et al., 2009) that investigate both individual and school-level use of
illicit substances. One of the inherent drawbacks of MTF is that par-
ticipants most at-risk are often missed in data collection due to
absenteeism and attrition. As a consequence, this method may
result in underreported illicit drug use in these samples due to
the fact that individuals at the highest risk are not included in
the analyses. The current study investigates early onset of drug
use among illicit drug users, the very sample that MTF is most
likely to miss.
The findings presented here have important implications for
urban areas such as Baltimore. In addition to a high prevalence of
illicit drug use (SAMHSA, 2010a), Baltimore also has a high incidence
371
of HIV/AIDS, ranking the city second among metropolitan areas in the
United States with upwards of 30% of cases attributable to IDU
(Maryland Department of Health and Mental Hygiene, 2008). More-
over, substance use has a strong link to HIV/AIDS and it is estimated
that approximately 64% of individuals diagnosed with HIV/AIDS
have used a non-injection illicit drug and 17% have used an injection
drug in their lifetime (SAMHSA, 2010b). Interventions should target
the early onset of substance use and polysubstance use, as it is an im-
portant risk factor for later substance use behaviors such as IDU. As
both injection and non-injection drug use have a strong link to HIV,
delaying the early onset of drug use until executive functioning is
more fully developed, may help to avert illicit drug use exposure
and high-risk environments. Although this study has shown that
early onset of alcohol and polysubstance use is an important predictor
of IDU in adulthood, researchers should continue to investigate
whether early onset substance use alters neuropsychological devel-
opment in a way that increases the risk for substance use in adult-
hood. Future research should seek to expand the literature on early
onset polysubstance use and its effects on neurocognitive develop-
ment and executive functioning.
Role of funding sources
Funding sources for this study had no role in the design of the study, data collection,
data analysis, data interpretation, writing of the manuscript, or decision to submit for
publication.
Contributors
Rebecca Trenz designed the study, conducted the analysis, and led the writing of the
article. Michael Scherer, Paul Harrell, Julia Zur, and Ashish Sinha conducted literature
searches, provided summaries of previous research, and collaborated on the final presen-
tation of the article. William Latimer was the principal investigator for this study. All
authors contributed to and have approved the final manuscript.
Conflict of interest
None.
Acknowledgments
This study was supported by grants R01DA014498 and T32DA007292 from the
National Institute on Drug Abuse.
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